The Cleanliness Differences of Root Canal Irrigated with 0.002% Saponin of Mangosteen Peel Extract and 2.5% Naocl

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Dental Journal (Majalah Kedokteran Gigi) 2015 June; 48(2): 104–107 Research Report

The cleanliness differences of root canal irrigated with 0.002% saponin of mangosteen peel extract and 2.5% NaOCl

Anis Sakinah, Laksmiari Setyowati, and Devi Eka Juniarti Department of Conservative Dentistry Faculty of Dental Medicine, Universitas Airlangga Surabaya-Indonesia

abstract Background: Root canal treatment consists of preparation, sterilization, and obturation. During root canal preparation, debris is smeared over the dentinal surface forming a smear layer. Smear layer will reduce the attachment of root canal filling materials. Organic material in smear layer can be substrated for microorganism. Preparation of root canal should be followed by irrigation. NaOCl is common irrigation solution in endodontics. It has been very effective for their disinfecting and tissue-dissolving properties, but it is incapable of removing the smear layer. On the other hand, saponin of mangosteen peel extract has an ability as a surfactant to lower the surface tension, and it can dissolve debris containing of anorganic and organic materials. Purpose: This study aims to know the differences between 2.5% NaOCl and 0.002% saponin of mangosteen peel extract in removing the debris in the root canal after the preparation procedure. Method: Three groups of teeth (7 teeth in each) were instrumented with K-file and irrigated as follow: group 1 (control) with aquadest; group 2 with 2.5% NaOCl; and group 3 with 0.002% saponin of mangosteen peel extract. Furthermore, those teeth were split horizontally and longitudinally 4mm above the apical. The apical third of root canal walls was observed by a scanning electron microscope (SEM). Result: There were significant differences between each group (p<0.05). Median value of the group 3 was score 1 considered as the smallest value. It indicates that Group 3 with 0.002% saponin of mangosteen peel extract was the cleanest group. Conclusion: It can be concluded that 0.002% saponin of mangosteen peel extract can clean the smear layer of the root canal better than 2.5% NaOCl.

Keywords: Saponin; mangosteen peel extract; NaOCl; debris

Correspondence: Laksmiari Setyowati, c/o: Departemen Ilmu Konservasi Gigi, Fakultas Kedokteran Gigi Universitas Airlangga. Jl. Mayjend. Prof. Dr. Moestopo No. 47 Surabaya 60132, Indonesia. E-mail: [email protected]

introduction into dentinal tubules may cause the reduction of surface tension of irrigants during instrumentation. Removal of Endodontic treatment is a procedure to maintain teeth the smear layer may enhance the penetration of sealers into for long time, consisting of three main steps of preparation, dentinal tubules and the adaptation of obturation materials sterilization, and obturation. One of the primary reasons to the root canal walls.2,3 for irrigating root canal is to ensure the cleanliness of Several irrigants and irrigant delivery systems are the canals prior to obturation. This cleanliness involves available, which behave differently and have relative both elimination of microorganisms and removal of advantages and disadvantages. Common root-canal organic matter.1 The procedure of root canal preparation irrigants consist of sodium hypochlorite (NaOCl), can produce smear layer, involving organic material, chlorhexidine gluconate, alcohol, hydrogen peroxide and odontoblastic processes, bacteria and blood cells. ethylene diamine tetra acetic acid (EDTA).4 However, the The presence of an infected smear layer may prevent most effective and commonly used is NaOCl. They have antimicrobial agents from gaining access to the infected a unique ability to dissolve necrotic tissue and organic dentinal tubules. Increased penetration of smear material components of the smear layer. In general, the concentration

Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 56/DIKTI/Kep./2012. Open access under CC-BY-SA license. Available at http://e-journal.unair.ac.id/index.php/MKG Sakinah, et al./Dent. J. (Majalah Kedokteran Gigi) 2015 June; 48(2): 104–107 105 of NaOCl commonly used is 2.5%, since this concentration then cotton pellets were put at the orifice and closed with has the ability to dissolve the tissue and has the power as temporary seals. All roots were grooved longitudinally antibiofilm.5 Nevertheless, NaOCl also has some negative on the buccal and lingual surfaces, and horizontally at the effects. NaOCl has a toxic effect on the tissue, and can apical third (4 mm from apex) with a small round diamond cause allergic reactions.6 NaOCl is alkaline and corrosive to bur, avoiding penetration into the cavity. The roots were metals that can damage the instrument used. Thus, NaOCl then split longitudinally with a small chisel into two halves. cannot dissolve inorganic dentin particles and cannot Roots that have been cut were placed on the sample holder, prevent the formation of smear layer during instrumentation and coating process was performed. process.4 NaOCl solution can cause pain to the periapical All specimens were examined using Hitachi TM tissues and swelling spontaneously.5 3000 scanning electron microscope (SEM) with 1000x Mangosteen fruit has the latin name Garcinia magnification at the apical third. Scoring was performed mangostana L. Mangosteen is being used to heal diarrhea, by three observers. Assessment of the cleanliness of the tonsillitis, whitish, dysentery and toothache. Mangosteen root canal was then conducted with transparent plastic tools peel can be used as a medicine for ulcers, dysentery, divided into 12 fields. Transparent plastic was attached diarrhea and uric acid.8 Methanol extract of mangosteen peel to a picture, and an assessment was determined by the (Garcinia mangostana L.) contain saponin, triterpenoids, percentage for each field. The percentage results were tannins, polyphenols, flavonoids and alkaloid.9 Mangosteen averaged and converted into a score. peel consists 1.82% of saponin.10 Due to the presence of Superficial debris was independently subjected to a a lipid-soluble aglycone and water-soluble sugar chain standardized semiquantitative evaluation in four grades in their structure (amphiphilic nature), saponin is surface based on the classification of Gutmann et al. (1994). active compound with detergent, wetting, emulsifying, and Criteria for the scoring were as follow: score 1: little or foaming properties, so saponin can dissolve the organic and no superficial debris covering up to 25% of the specimen; inorganic debris of dentin.11 Therefore, this study aims to score 2: little to moderate debris covering between 25 and study the effects of saponin extract of mangosteen peel on 50% of the specimen; score 3: moderate to heavy debris the cleanliness of the root canal walls. covering between 50 and 75% of the specimen; and score 4: heavy amounts of aggregated or scattered debris over 75% of the specimen. materials and methods The data were processed and analyzed using a frequency test to determine the median of each treatment group, and This study is a laboratory experimental research with also a non-parametric test, Kruskal-Wallis test, to determine post-test only control group design. Twenty-one mandibular differences between groups of aquadest (control), saponins, premolars were extracted for orthodontic treatment with and NaOCl. Mann-Whitney test was conducted to determine the provisions of a single root canal with apical tip that has the differences between the treatment groups. grown perfectly by inserting files no. 15 due to the working length. It means that the root canal had to be straight without any caries, restoration, and obstruction. results The teeth were stored in isotonic saline solution to avoid any effect that fixative might have on the dissolution of There were 7 pieces of tooth samples with 0.002% organic tissue then randomly selected and divided in the saponin extract of mangosteen peel median with median three groups. Access opening was done with endo access score 1. It indicates that there was little or no superficial bur, and working length was determined. Afterwards, root debris covering up to 25% of the specimen. Meanwhile, canals were prepared using a needle K-File no. 15 to no. the score of the group with 2.5% NaOCl was 2. It means 60 using standard techniques. Each sample was irrigated that there was little to moderate debris covering between by 3 ml of treatment solution with a pressure of 1 atm 25% and 50% of the specimen. And the score of the group using irrigation needle 27 G. After irrigated, root canals with aquadest (control) was 3. It indicates that there was were rinsed with aquadest to stop the chemical process. moderate to heavy debris covering between 50 and 75% Root canal wall was dried with paper points 3 times, and of the specimen (Table 1).

Table 1. The results of frequency test in each group

No. Group N Median SD 1. Aquadest (control) 7 3 0.48795 2. 2.5% NaOCl 7 2 0.53452 3. 0.002% Saponin extract of mangosteen peel 7 1 0.53452

Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 56/DIKTI/Kep./2012. Open access under CC-BY-SA license. Available at http://e-journal.unair.ac.id/index.php/MKG Table 1. The results of frequency test in each group No. Group N Median SD 1. Aquadest (control) 7 3 0.48795

2. 2.5% NaOCl 7 2 0.53452 3. 0.002% Saponin extract of 7 1 0.53452 Table 1. The results of frequency test in each group mangosteen peel No. Group N Median SD

1. Aquadest (control) 7 3 0.48795

2. 2.5% NaOCl 7 2 0.53452 3. 0.002% Saponin extract of 7 1 0.53452 mangosteen peel

106 Sakinah, et al./Dent. J. (Majalah Kedokteran Gigi) 2015 June; 48(2): 104–107

A B C

Figure 1. The results of SEM with 1000x magnification on the root canal walls irrigated with Figure(a) 0.002% 1. saponinThe results extract of of SEM mangosteen with 1000x magnification on the root canal walls irrigated with (a) 0.002% peel; (b) 2.5% NaOCl; (c) aquadest (control). saponin extract of mangosteen peel (b) 2.5% NaOCl; (c) aquadest (control).

Furthermore, the results of Kruskal-Wallis test showed Thus, this study was conducted to analyze the that there were significant differences between the root differences of 0.002% saponin extract of mangosteen peel canal wall cleanliness irrigated with aquadest water group and 2.5% NaOCl in cleaning debris on the surface of the (control), 2.5% NaOCl and 0.002% saponin extract of root canal walls. The examination of debris was conducted mangosteenFigure 1. The peel r (p<0.05).esults of Mann-WhitneySEM with 1000x test magnificationshowed that onthrough the root a laboratorycanal wall researchs irrigated using with S E (a)M. The0.002% results of there was a significant difference between the root canal wall SEM were evaluated with the photomicrograph using the cleanliness sofaponin the two extract groups, of aquadest mangosteen (control) peel and (b) 2.5%2.5% NaOCl;criteria (c) of aquadest how much (control). debris covering the walls of the root NaOCl, about 0.015 (p<0.05). There was also a significant canal. The apical third was then selected since this section difference between the root canal wall cleanliness of the is smaller than the other parts, so the root canal debris can two groups, aquadest (control) and 0.002% saponin extract be more easily buried in this part.13 of mangosteen peel, about 0.001 (p <0.05). And, there The results of SEM photomicrograph assessment was a significant difference between the root canal wall showed a little debris on the surface of the root canal walls cleanliness of the two groups, 2.5% NaOCl and 0.002% and plenty of opened dentin tubules on the canal walls Mangosteen peel extract, about p=0.010 (p<0.05). Finally, irrigated by 0.002% saponin extract of Mangosteen peel. further analyzing of the data was conducted using the Meanwhile, the surface of the root canal wall and dentin scanning electron microscope photomicrograph (SEM) tubules irrigated with 2.5% NaOCl were covered with with the results as shown on Figure 1. debris, and opened dentin tubules were rarely seen. In addition, 0.002% saponin extract of mangosteen peel was better in cleaning debris on the canal wall because 7 discussion it has surfactant effects able to bind impurities, such as organic and inorganic debris. Surfactants can clean up by The main purpose of irrigation is generallly to clean lowering the surface tension of the root canal wall covered root canal prior to obturation and also to eliminate with debris, consequently, the surface was wetted. Saponins microorganisms and organic components. Based on particles, as a result, can penetrate into the dentin tubules previous researches, it can be said that 41.5% of researchers and bind with debris to form an emulsion in water, and then support the cleaning process because the smear layer can the emulsion will be held in suspension to be carried out block the filling materials contacting with the root canal by the water, so root canal debris will be removed and the wall. Organic debris of the smear layer even can became dentin tubules will be opened.14 the media for growth of bacteria.12 7 Saponins can remove organic debris because it has a The most effective irrigation material often used lipophilic group which can bind impurities, such as fat. is NaOCl. NaOCl has a good antibacterial ability. As Saponins then form a stable emulsion that can be dispersed a lubricant, NaOCl can remove the organic debris and into water, so the debris will be carried out by irrigant. smear layer on root canal. However, NaOCl has some Saponins also can remove inorganic debris because its disadvantages because it has a toxic effect on the periapical hydrophilic group can bind Ca2+ ions in the root canal wall tissue and can cause allergic reaction.4 that contains of hydroxyapatite, so saponins can remove Saponins in mangosteen peel contains approximately organic and inorganic debris of root canal wall.3 1.82% surfactant properties, often referred to as natural The group irrigated with 2.5% NaOCl showed poor detergent. Surfactant properties due to the non-sugar results compared to the group irrigated with 0.002% saponin group can be called sapogenin. Sapogenin which have both extract of mangosteen peel. This is because NaOCl does not hydrophilic and lipophilic groups are able to lower surface have any ability to clean up inorganic debris. This irrigant tension to function as detergents, emulsifiers, wetting and actually has a chemical reaction stage only with organic foaming, consequently, it can dissolve impurities, such as materials, namely saponification reaction. Dissolved organic and inorganic debris dentin.10 organic will be formed when the saponification reaction